| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,905 |
1,029 |
$360K |
| D1206 |
Topical application of fluoride varnish |
13,649 |
13,154 |
$333K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,921 |
2,490 |
$322K |
| D1120 |
Prophylaxis - child |
11,291 |
11,141 |
$316K |
| D0120 |
Periodic oral evaluation - established patient |
11,933 |
11,768 |
$282K |
| D1351 |
Sealant - per tooth |
8,213 |
2,435 |
$225K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,565 |
4,045 |
$139K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,057 |
1,569 |
$130K |
| D1110 |
Prophylaxis - adult |
2,358 |
2,327 |
$84K |
| D1999 |
|
7,933 |
7,302 |
$79K |
| D0272 |
Bitewings - two radiographic images |
4,370 |
4,314 |
$55K |
| D9420 |
|
639 |
617 |
$54K |
| D0330 |
Panoramic radiographic image |
1,956 |
1,925 |
$45K |
| D0274 |
Bitewings - four radiographic images |
2,086 |
2,068 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
456 |
450 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
845 |
835 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,474 |
2,381 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
525 |
511 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
157 |
87 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
94 |
66 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
147 |
147 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,172 |
929 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
13 |
$2K |
| D2920 |
|
19 |
12 |
$360.00 |